Infection Control Failures in Blood Draws, Precautions, and Kitchen Hygiene
Penalty
Summary
Contracted staff failed to follow safe and effective blood-draw practices by attempting to draw a resident's blood in the main dining room while the resident was eating breakfast and another resident was present at the table. The contracted staff stated they had been told by a facility staff member that they could draw blood in the dining room if the resident consented, and they confirmed they had not received any additional training on the facility's infection control expectations. Facility staff interviews revealed that contracted staff were expected to follow the facility's guidelines and not perform blood draws in common areas, but no additional training or clear communication of these expectations had been provided to the contracted staff. The facility did not implement appropriate transmission-based precautions (TBP) for residents on droplet and contact precautions. For a resident on droplet precautions due to parainfluenza virus pneumonia, there was no signage on the outside of the door, and personal protective equipment (PPE) was stored inside the room rather than outside, contrary to facility policy. Staff interviews confirmed that signage and PPE placement did not meet policy requirements, and documentation showed the resident was on droplet precautions at the time of the observation. For another resident on contact precautions due to a methicillin-susceptible Staphylococcus aureus (MSSA) infection, PPE was inconsistently placed, and staff were observed entering the room without donning PPE, despite policy requiring PPE to be donned before room entry. In the kitchen, staff failed to follow proper hand hygiene and glove use protocols. One staff member was observed sweeping the floor with gloved hands and then handling food items without changing gloves. Another staff member handled both soiled items and ready-to-eat food with the same pair of gloves, without changing gloves or washing hands between tasks. Facility policy required gloves to be changed between tasks and for staff to adhere to hygienic practices to prevent food contamination, but these procedures were not followed during the observations.